Provider Demographics
NPI:1760043673
Name:STEVENS, TRACY LEE (CNM/WHNP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LEE
Last Name:STEVENS
Suffix:
Gender:F
Credentials:CNM/WHNP
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:LEE
Other - Last Name:PERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2222 NE 130TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-1705
Mailing Address - Country:US
Mailing Address - Phone:503-754-6296
Mailing Address - Fax:
Practice Address - Street 1:2222 NE 130TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-1705
Practice Address - Country:US
Practice Address - Phone:503-754-6296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-23
Last Update Date:2019-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201903006NP-PP363LW0102X
OR201901674NP-PP367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health